The "Original" office based neck rejuvenation technique using suspension sutures.

Introduction

Over the past 17 years many cosmetic neck lift operations have been designed to restore the loss of the youthful neck and jaw line. None have been so successful and long lasting as the Suture Suspension Technique in both men and women. Recent modifications of this operation have further increased its utility and effectiveness to a wider range of patients. With the availability of the new Contour Thread™ suture, the possibility for a total neck rejuvenation in the office setting, without intravenous or general anesthesia has now become a reality.

G String Neck Lift Procedure

Both the original formal Suture Suspension Technique and the Contour Thread "G" String Technique utilize permanent sutures that create a new "supporting ligament", that holds the platysma muscle in an internal and superior "vector" which restores both the cervicomental angle and mandibular borders. This creates a youthful neck and jaw line.

The "G" String neck lift Technique now allows the "appropriate patient" to obtain optimal neck and jaw line improvement in the office setting under local anesthesia.

Patient Selection

The ideal patient for the "G" String neck lift technique is the Class 1 or 2 neck deformity previously described. In summary, these neck classes include those patients with just loose platysma muscle with small amounts of submental and submandibular fat. Both patient types have naturally deep submental angles and strong mandibular bony outlines.

Procedure and Technical Details

The patient is given oral sedative meds (Valium 5 mg, Percocet 5 mg, Dramamine 10 mg), 20 minutes prior to local anesthesia administration. The patient is marked with a surgical marker in a semi-sitting position outlining the lower mandibular border and the depth of the intended cervicomental angle. A second small 0.5 cm line is placed in the submental crease area immediately below the chin. A small postauricular ellipse is marked bilaterally in the mastoid-conchal groove (approximately 1.5 cm in length). These areas are then injected with 0.5% Lidocaine and epinephrine 1:200,000. Usually, 50-60 cc are used for local infiltration for the complete procedure and a 10-15 minute wait is utilized for maximum vasoconstriction and local anesthetic effects. A small stab incision is made at the submental area and using an 18 gauge mushroom cannula and a 10cc syringe, the submental area and fat is suctioned. Usually approximately 10-12 cc of fat are removed on average. Additional stab incisions are made in the postauricular areas and using the 7 inch long 18 gauge Mercedes cannula and a 10 cc syringe, the submandibular borders bilaterally are suctioned. Here, approximately 5-6 cc of fat on each side are removed on average. These maneuvers help further define the neck angle and jaw line.

A small postauricular ellipse of skin is excised bilaterally and this is also accomplished to aid in placement of the Contour Thread needles later in the procedure. The skin adjacent to the ellipse is undermined minimally for approximately 1 cm.

A second stab incision is made at the intended cervicomental angle and here skin is undermined with a blunt Steven's scissors for approximately 1 cm around the incision site. This helps avoid any skin dimpling after the placement of the Contour Threads.

A CT 400 Contour Thread is placed through the stab incision at the intended cervicomental angle and then placed into the platysma muscle tracking below the site of the submandibular suction. The needle remains intramuscular until the mandibular angle is reached where it becomes subcutaneous. The needle tip appears visible at the postauricular ellipse. It then perforates the mastoid fascia and is pulled through. A small mosquito clamp must be placed at the mid-portion of the CT 400 suture to keep the midline from being pulled through the small cervicomental stab incision. The second needle is then placed through the cervicomental stab incision leaving a small external loop with a mosquito clamp attached outside the skin. The second needle is then passed in identical fashion. The needles are cut leaving the two free ends to be tied later.

The second CT 400 Contour Thread is now used by placing the first needle through the loop and the needle itself is passed as described previously through the muscle and perforating the mastoid fascia. The second needle of the same suture is passed above the loop creating an interlocking effect of the 2 CT 400s at the new cervicomental angle site. At this time, the mosquito clamp is removed and the 2 CT 400s are pulled through the small stab incision at the new cervicomental angle.

The two free ends at each mastoid area are now tied to each other using at least 5 knots. Care should be taken to avoid over-tightening of the suture since the knots are now tied on the barbed segment of the CT 400 suture.

A free 4-0 nylon suture is then placed over the Contour Thread knot to help keep it buried as well as reinforce it to the mastoid fascia.

After accomplishing this maneuver bilaterally with the appropriate tension, both threads then result in elevating the cervicomental angle both interiorly and superiorly and have defined the submandibular borders. The barbs are inset by using gentle pressure from the lateral to medial direction. This is accomplished with the fingertips. This fixes the barbs intramuscularly in the medial portion of the platysma further defining the cervicomental and submandibular borders.

Post-OP Care

The skin is dressed with strips of brown surgical tape or Steri-strips over the cervicomental angle and suction sites at the submandibular borders. A mild compressive rubber dressing or Ace wrap are used for 24 - 48 hours post-operatively along with oral Tylenol or Tylenol with Codeine as needed for pain.

The dressing is removed in the office along with the skin tape by the surgical staff after 24-48 hours. New small pieces of Steri-strips are placed on the submental incision site. The patient is instructed to limit their activity for an additional 48 hours when they can remove the residual Steri-strips described above. Sutures in the submental area are removed in one week and in the postauricular area in two weeks if they have not dissolved at that time. Full activity including heavy exercise is limited to four weeks. Activities of daily living can be resumed as early as when the dressing is removed in 12-24 hours.

Results and Discussion

The "G" String technique for neck rejuvenation using Contour Threads has resulted in excellent youthful contours of the neck and jaw line when used for the correct category of surgical candidates. The patients have been limited to Class 1 and 2 neck categories and have all had their procedures done under local anesthesia with or without oral sedation in the office setting as an outpatient.

The long-term follow up has yet to be accomplished, but at the 12 month post-op period the results have continued to improve with no relapse in neck or jaw line contours present. As with the more involved "Suture Suspension Technique" there is no sensation of the suspension suture, nor any limitation of range of motion to the neck or jaw lines after the intial few weeks. The incisions are virtually unnoticeable and recovery is limited to 3-5 days on average. It is the author's opinion that the "G" String technique will fill the niche created by the new patient demands for rapid outpatient office based procedures that deliver both immediate short-term and long-term results. This approach for neck rejuvenation should result in an excellent long-term result, since it is based on identical procedural concepts as the original suture suspension technique of the neck, which has stood the test of time over the past 13 years.